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Ann Thorac Surg 1999;67:471-477
© 1999 The Society of Thoracic Surgeons

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Original Articles

Randomized trial of intermittent antegrade warm blood versus cold crystalloid cardioplegia

^a Cardio-thoracic Intensive Care Unit, Department of Cardio-thoracic and Vascular Surgery, and Department of Cardiac Anesthesia, University Hospital Saint Luc, Brussels, Belgium

Accepted for publication July 11, 1998.

Address reprint requests to Dr Jacquet, Intensive Care Unit, University Hospital Saint-Luc, 10 Ave Hippocrate, 1200 Brussels, Belgium

	Abstract

Top Abstract Introduction Patients and methods Results Comment References

 
Background. We performed a prospective randomized trial to compare intermittent antegrade warm blood cardioplegia with intermittent antegrade and retrograde cold crystalloid cardioplegia.

Methods. Two hundred consecutive patients scheduled for isolated coronary bypass surgical procedures were randomized into two groups: Group 1 (n = 92) received cold crystalloid cardioplegia with moderate systemic hypothermia, group 2 (n = 108) received intermittent antegrade warm blood cardioplegia with systemic normothermia. Preoperative, intraoperative, and postoperative data were prospectively collected.

Results. For the same median number of distal anastomoses, cardiopulmonary bypass duration and total ischemic arrest duration (57.3 ± 20.5 versus 75 ± 22.1 minutes, p < 0.001) were shorter in group 2 than in group 1. Apart from a higher right atrial pressure in the cold cardioplegia group, no hemodynamic difference was observed. Aspartate aminotransferase, creatine kinase-MB fraction, and cardiac troponin I levels were significantly lower in group 2 than in group 1. Outcome variables were not significantly different.

Conclusions. Intermittent antegrade warm blood cardioplegia results in less myocardial cell damage than cold crystalloid cardioplegia, as assessed by the release of cardiac-specific markers. This beneficial effect has only marginal clinical consequences. Normothermic bypass has no deleterious effect on end-organ function.

	Introduction

Top Abstract Introduction Patients and methods Results Comment References

 
Since its introduction by Salerno and colleagues [1] and Lichtenstein and associates [2], continuous warm blood cardioplegia has been routinely used by a growing number of surgeons. Both in vitro and in vivo studies have demonstrated the superiority of continuous warm blood cardioplegia over conventional cold cardioplegia with regard to myocardial metabolic and functional recovery [3, 4]. A major limitation is the flooding of cardioplegia in the operating field, which could hinder the surgeon. Interruption of the infusion is thus frequently necessary for technical reasons and is reported to have no deleterious effect on cardiac recovery, provided that the "time off cardioplegia" does not exceed 13 minutes [5]. Deliberate use of intermittent antegrade warm blood cardioplegia (IAWBC) has been proposed as a safe and reliable technique of myocardial protection, as reported by Calafiore and associates in a historical comparative study [6].

Body temperature during cardiopulmonary bypass (CPB) is another controversial issue [7, 8]. Indeed, hypothermia decreases end-organ oxygen consumption and offers some degree of protection during periods of low flow or low perfusion pressure, but it also has side effects (ie, on the coagulation cascade) [9]. Tissue protection during normothermia has also been questioned, especially cerebral protection, because some studies have reported a higher incidence of neurologic events [7].

Our study was initiated to evaluate, in a prospective randomized trial, the effect of IAWBC on myocardial protection and that of normothermic bypass on end-organ function compared with our previous usual practice of intermittent antegrade and retrograde cold crystalloid cardioplegia with moderate hypothermia.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment References

 
With approval of the institutional ethics committee, 200 consecutive patients scheduled for isolated coronary bypass surgical procedures between December 1995 and November 1996 gave their informed written consent to participate in the study. Patients undergoing emergent procedures or combined valvular and coronary surgical procedures, as well as those with a carotid stenosis greater than 80% were excluded from the study. Eligible patients were randomized into two groups: Group 1 (n = 92) received combined antegrade and retrograde cold crystalloid cardioplegia with moderate systemic hypothermia; group 2 (n = 108) received intermittent antegrade normothermic blood cardioplegia with systemic normothermia. Anesthesia was induced with sufentanil (3 µg/kg body weight) and midazolam (0.05 mg/kg) and maintained by a continuous administration of sufentanil (1 to 1.5 µg · kg^-1 · h^-1) and propofol (0.1 to 0.25 mg · kg^-1 · h^-1). Muscle paralysis was obtained with pancuronium (0.1 mg/kg). All patients received tranexamic acid (10 mg/kg) as a bolus at induction followed by a continuous infusion of 1 mg · kg^-1 · h^-1 during CPB. Cardiopulmonary bypass was instituted with a heparin-coated circuit (Duraflo II; Baxter, Irvine, CA) and a heparin-coated hollow fiber membrane oxygenator (Spiragold; Baxter). The circuit was primed with 1.5 L of plasmalyte and 2 mL/kg of 15% mannitol. Systemic heparin was given to achieve an activated clotting time greater than 450 seconds (±300 U/kg). In group 1, cardiac arrest was obtained by infusion of 500 mL of cold crystalloid solution (1,000 mL Hartman, 14 mEq KCl, 8 mEq NaHCO₃, 25 mEq MgSO₄, procaine 200 mg) into the aortic root, combined with 500 mL of the same solution infused in the coronary sinus at a pressure of 40 mm Hg or lower. An additional 500-mL solution without procaine was administered every 60 minutes or whenever necessary (eg, at resumption of electrical activity). Body temperature was allowed to decrease to a minimal temperature of 30°C. Rewarming was initiated during completion of the last distal anastomosis. In group 2, cardiac arrest was achieved by intermittent infusion of normothermic hyperkalemic blood in the aortic root. Blood was collected from the oxygenator and infused into the aortic root using a roller pump. The tubing was connected to a syringe pump containing a solution of 2 mEq K⁺/mL. The composition and rate of administration are presented in Table 1. The time elapsed between two infusions, which defines an ischemic arrest period, never exceeded 15 minutes. During CPB, blood temperature was maintained around 37°C.

A 12-lead electrocardiogram was recorded at the same time points for detection of ischemic episodes or Q-wave infarction, or both. Additional recordings were performed if clinically necessary. Blood was drawn for protein and ion determination and for enzymatic assay (creatine kinase [CK] and aspartate aminotransferase) simultaneously. For CK-MB mass measurement and for cardiac troponin I (cTnI) dosage, blood was immediately centrifuged and frozen for later determination. The CK-MB mass was measured using a fluorometric enzyme assay and cTnI using a specific enzyme-linked immunosorbent assay (Stratus, Dade, Miami, FL). The area under the curve for these marker levels was calculated by a linear trapezoidal rule. In the ICU, anesthesia was systematically maintained until the sixth postoperative hour with a continuous infusion of sufentanil (0.5 µg · kg^-1 · h^-1). A propofol infusion was adapted for sedation (0.5 to 2 mg · kg^-1 · h^-1) until patients were ready for extubation. Intravenous paracetamol (2 g) or piritramide (2 to 4 mg) was administrated for analgesia. Extubation was performed as soon as the patients were able to maintain adequate gas exchange with a pressure support at 5 cm H₂O above positive end-expiratory pressure and a respiratory rate less than 20 breaths per minute and if they were hemodynamically stable, adequately rewarmed, and not bleeding.

Colloids (gelatine or hydroxyethylstarch) were infused if pulmonary artery occlusion pressure was less than 15 mm Hg and if one of the following criteria was not met: mean blood pressure greater than 65 mm Hg, heart rate less than 110 beats per minute, cardiac index greater than 2.5 L · min^-1 · m^-2, or urine output less than 0.5 mL · kg^-1 · h^-1. If these values were not reached after volume loading, inotropic or vasoactive drugs, or both, were administered according to the hemodynamic data. Homologous red blood cells were given for a hemoglobin level greater than 8.5 to 9 g/100 mL. Fresh-frozen plasma, cryoprecipitate, or platelets were given only to hemorrhagic patients presenting with abnormal hemostasis.

Patients were usually discharged from the ICU on the second posterative day and left the hospital 1 week later.

For between-group comparisons, unpaired t tests or Mann-Whitney U tests were performed according to the distribution for continuous variables and the Mann-Whitney U test for discrete variables. For comparison of serially recorded variables, an analysis of variance for repeated measures was used. If a difference was found, a t test was performed for pairwise comparisons. Proportions in the two groups were compared using the ² test. Differences were considered statistically significant at a p value less than 0.05.

	Results

Top Abstract Introduction Patients and methods Results Comment References

 
The preoperative characteristics of the two groups are presented in Table 2. Both groups were similar, except for semiurgent procedures (patients requiring intravenous nitroglycerin for relieve of their anginal symptoms), which were more frequent in group 2. Table 3 summarizes the intraoperative data. For the same median number of distal anastomoses, total ischemic arrest and CPB duration were shorter in group 2. Mean blood pressure during CPB was significantly lower in group 2, and more patients in this group required vasopressors to maintain their mean blood pressure at greater than 50 mm Hg. Ventricular fibrillation after aortic cross-clamp release was significantly more frequent in the cold cardioplegia group.

View larger version (33K): [in this window] [in a new window]   Fig 1. Comparison of hemodynamic data between the two study groups: (A) cardiac output, (B) mean pulmonary artery pressure, (C) central venous pressure, and (D) right ventricular stroke work index (R.V.S.W.I.). Open bars indicate cold cardioplegia; solid bars indicate normothermic cardioplegia. (T-1 = induction of anesthesia; T0 = arrival in intensive care unit; T1 = 4 hours after operation; T2 = 8 hours after operation; T3 = postoperative day 1; T4 = postoperative day 2; * = p < 0.05.)

View larger version (20K): [in this window] [in a new window]   Fig 2. Comparison of markers of cardiac cell damage in the two study groups: (A) aspartate aminotransferase (ASAT); (B) creatine kinase-MB mass assay (CK-MB); (C) cardiac troponin I. (* = p < 0.05; ** = p < 0.01; other abbreviations as in Fig 1.

View larger version (12K): [in this window] [in a new window]   Fig 3. Comparison of cardiac troponin I (cTn-I) levels in patients without electrical countershock. (* = p < 0.05; ** = p < 0.01; other abbreviations as in Fig 1.)

View larger version (33K): [in this window] [in a new window]   Fig 4. Comparison of mean area under cardiac troponin I (cTn-I) curve until day 2 after operation.

Total chest tube drainage was 835 mL in group 1 and 792 mL in group 2 (p = 0.47). Homologous blood transfusion was also identical in both groups (median, 509 mL in group 1 versus 538 mL in group 2, p = 0.58). As presented in Figure 5, total fluid balance (including cardioplegic solution) during the first 48 hours was higher in group 1 than in group 2 at all time points.

View larger version (16K): [in this window] [in a new window]   Fig 5. Comparison of cumulative fluid balance until postoperative day 2. (O.R. = in the operating room; * = p < 0.01; other abbreviations as in Fig 1.)

	Comment

Top Abstract Introduction Patients and methods Results Comment References

 
The deliberate use of IAWBC was first reported by Calafiore and colleagues [6] in a retrospective study comparing 250 patients operated on with this technique with their last 250 patients operated on with cold blood cardioplegia. They reported less inotropic support requirement, less CK-MB release, and a shorter stay in the ICU using IAWBC. A prospective, randomized study comparing IAWBC with cold blood cardioplegia by Pelletier and associates [10] also showed less release of CK-MB and troponin T in the IAWBC group.

Because interruption of cardioplegia is synonymous with warm ischemia and is thus believed to be harmful, these surprising results were challenged by in vitro studies. If some studies seemed to indicate poor metabolic and functional recovery when warm blood cardioplegia was interrupted for 10 minutes [11, 12], more recent studies in isolated pig or rabbit hearts suggest that no negative effect on the myocardium is observed after an interruption of up to 10 minutes [13, 14].

Encouraged by these early clinical and laboratory results, we decided to compare IAWBC with our routine practice of cold crystalloid cardioplegia administered by a combined antegrade and retrograde route, acknowledging that the route of administration is different and could influence the results.

Our study demonstrates a significant reduction of myocardial cell damage with the use of IAWBC. Specific markers of cardiac cell lesions, especially cTnI, are indeed significantly lower after normothermic cardioplegia at each time point until the second postoperative day. Even if we exclude patients requiring electrical shock for ventricular fibrillation, the difference remains highly significant.

The mean peak value and the mean area under cTnI curves until postoperative day 2 were also significantly different, indicating that different rates of myocardial release cannot explain the observed disparity in blood levels. A dilutional factor can also be excluded because hematocrit and protein levels are the same in both groups. Because cTnI has been shown to be highly specific for myocardial cell damage and to be unaffected by skeletal muscle lesions or renal insufficiency [15, 16], this finding clearly indicates that fewer myocardial cell lesions occurred in the normothermic group.

However, few consequences, if any, were observed in the postoperative hemodynamic profiles. Right atrial pressure in the cold cardioplegia group at 4 hours after operation and at postoperative day 1 was higher, but pulmonary artery pressure and right ventricular stroke work index were not statistically different, suggesting that higher filling pressures were required in the "cold" group to maintain right ventricular function. Moreover, the proportion of patients requiring inotropic support or an intraaortic balloon pump was the same in both groups. A higher proportion of our patients required inotropic support than those evaluated by Lichtenstein and colleagues [5] and Calafiore and associates [6]. Both more liberal criteria for the use of inotropic drugs and longer total ischemic duration in our normothermic groups (57 minutes of a cross-clamping time of 69 minutes) can explain this difference between the present study and previous reports. If, as suspected, longer intraoperative ischemia increases the need for inotropic support, this assumption certainly raises some concern as to the outcome of patients with a lower ejection fraction and deserves further investigation. However, even if the ischemic duration was relatively long in our study, cTnI release was lower in the normothermic group and inotropic requirements for normothermia and cold cardioplegia were the same.

In accordance with previous studies, the incidence of ventricular fibrillation after cross-clamp release was significantly lower in the normothermic cardioplegia group. The incidence of ventricular or supraventricular arrhythmias and the need for temporary pacing were not different at any time until patient discharge from the hospital.

During bypass, significantly more patients in the normothermic group required vasoconstrictors to maintain their mean blood pressure above 50 mm Hg, but this requirement seems not to be associated with any side effect, especially with respect to mammary artery flow and the incidence of ischemic episodes. Although more patients in the normothermic group were treated with angiotensin-converting enzyme inhibitors, neither angiotensin-converting enzyme inhibitors nor calcium entry blockers were associated with an increased need for vasoconstrictors.

Total fluid balance was higher in the cold cardioplegia group. The use of hyperkalemic patient blood infused through a side arm of the CPB arterial line obviates the need for infusing extra fluid to obtain cardioplegic arrest in the normothermic group. At the end of operation, and despite increased diuresis, the cold cardioplegia group had a total fluid balance ±700 mL higher, and this difference was still ±800 mL on the second postoperative day.

With regard to lung function variables, and as reported by Birdi and colleagues [17], no difference was noted in gas exchange and ventilation variables. We were also unable to show any difference in bleeding rate or blood product requirement, even after correction for body surface area and despite the well-known deleterious effect of cold temperature on hemostasis and platelet function [18]. This finding may be related to our systematic use of tranexamic acid and perhaps our use of heparin-coated circuits, which could have lowered the incidence of bleeding in the cold cardioplegia group [19, 20]. Moreover, hypothermia during bypass was moderate (mean lowest temperature, 31.4°C), with probably a moderate effect on hemostasis, which could explain the differences between our study and others [9].

A further concern, when using normothermic bypass, was neurologic outcome [7–10]. Our incidence of stroke was the same in both groups, but the number of patients in our study was too small to be conclusive because the incidence of this complication was low. It must be emphasized that glycemia was not a concern with our low cardioplegia volume and that mean blood pressure during bypass was maintained above 45 to 50 mm Hg. Even though the design of the present study was to maintain true normothermia in our patients during bypass, the actual lower temperature drifted below 35°C on average. This relatively small change in body temperature could have some protective effects on the central nervous system.

Finally, length of stay in the ICU and in the hospital were the same in both groups. However, these are very gross and nonspecific markers of outcome because they are influenced by numerous external factors independent of the cardioplegia or bypass temperature. For instance, because no stepdown unit is available in our hospital, patients were usually maintained in the ICU until the second postoperative day.

In conclusion, IAWBC results in less myocardial cell damage than cold crystalloid cardioplegia, as assessed by the release of cardiac-specific markers. Better right ventricular preservation is possible but does not result in less need for inotropic support. Normothermic bypass increases the need for vasoconstrictors during CPB without significant effects on end-organ function. However, the possibility of early extubation has to be addressed with another study design, and neurologic outcome has to be evaluated in a larger population.

	References

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Philippe H. Noirhomme Martin J. Goenen Robert A. Dion Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jacquet, L. M. Articles by Dion, R. A. Search for Related Content PubMed PubMed Citation Articles by Jacquet, L. M. Articles by Dion, R. A.